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Joseph Lee

Bernard Haylen

Oliver Daly

Christopher Maher

UGSA MUS sling workshops

SUI Pathophysiology 2016

Preamble

Pathophysiology & Etiology of SUI

Epidemiology

Assessment of UI

Management of SUI

Enhorning’s (pressure equalisation) Theory & Hammock Theory

(urethral backstop)

Conservative & Surgery

Management of intra & post operative complications

Case discussions

Womens HealthUrinary Incontinence – Australia: Prevalence

• stress incontinence peaked at 25.3% for females aged 35–44

• urge incontinence peaked at 24.2% for females aged 75 and over

• mixed incontinence peaked at 20.6% for females aged 55–64.

R Botlero Maturitas 62 (2009) 134–139

Categorise and Treat

SUI UUI

International Continence Society (ICS)International Urogynaecological Association (IUGA)

Stress49%2

Urgency 22%2

Urgency symptomsUrgency urinary incontinence (UUI) is

the complaint of involuntary

leakage accompanied by or

immediately preceded by urgency

Stress symptomsStress urinary incontinence (SUI) is the

complaint of involuntary leakage on

effort or exertion, or on sneezing or

coughing

Mixed29%2

Mixed symptoms

Definition of urinary incontinence

1. Haylen B et al. Int Urogynecol J 2010; 21: 5 – 26. Neurourol Urodyn 2010;29:4-202. Hampel C et al. Urology 1997; 50(suppl 6A): 4–14

� Stress Urinary Incontinence SUI

� Urge(ncy) Urinary Incontinence UUI (OAB Wet)

� Mixed Urinary Incontinence MUI = SUI + UUI

� Overflow

� Congenital

– Ectopic ureter, epispadias, bladder exostrophy, cloacal exostrophy

� Fistula (vesico - vaginal fistulae)

– Gynae Surg (hysterectomy, anterior repair, laparoscopic pelvic surgery)

– Obstetrics (Third World)

� Functional

– Delirium, Infection, Atrophic changes, Pharmacological,Psychological, Excess Urine Output,

Restricted Mobility, Stool Impaction (DIAPPERS)

Types of urinary incontinence

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� Bladder Neck hypermobility

� Intrinsic sphincter deficiency

� Detrusor overactivity

� Oversensitive bladder

� Hypotonic or acontractile detrusor

� Obstruction

� Combination of urgency and stress

� Leakage during ‡intra-abdominal pressure

� Involuntary leakage

� Strong desire to void

� Often one symptom predominant

� ‡ with age

� Bladder distension

� Frequent to constant dribbling

SUI UUI MUI Overflow

Types of urinary incontinence

� Congenital– Ectopic ureter, epispadias, bladder exostrophy, cloacal

exostrophy

� Fistula (vesico - vaginal fistulae)– Gynae Surg (hysterectomy, anterior repair, laparoscopic pelvic

surgery)

– Obstetrics (Third World)

� Functional– Delirium, Infection, Atrophic changes,

Pharmacological,Psychological, Excess Urine Output, Restricted Mobility, Stool Impaction (DIAPPERS)

Types of urinary incontinence

� Enhorning GE1,2

– Pressure equalization

– Urinary incontinence achieved

urethral pressure ≥ intravesical

pressure

– Bladder neck retropubic

position

– Hypermobility results in

unequal pressure transmission

– Procedures focussed on

stabilizing urethra in fixed

retropubic position

Pressure equalisation

Enhorning GE Acta Chir Scand 1961, Enhorning GE Urol Int 1976

� Delancey JO3

– Hammock hypothesis from cadaveric dissection

– Fixed anterior vaginal wall serves as support for urethra

– Disruption of vaginal wall attachments creates bellowing hammock

– Ineffective backstop for urethra

Urethral hammock support

MUS provide a suburethral backstop during increased Abd pressure

Delancey JO AmJOG 1994

Risk Factors for SUI – simple to complex

Risk factors for stress urinary incontinence. Adapted from Bump RC, Norton PA. Obstet Gynecol ClinNorth Am. 1998;25:723–746.

Genetics Association studies - SUI

Cartwright Systematic Review and Metaanalysis of genetic association studies of urinary symptoms and prolapse in women. AmJOG 2015

Stress urinary incontinence

OR 2.1 [1.4, 3.2 n= 190]

Forest plot of studies reporting associations between rs1800012 single-nucleotide

polymorphism (SNP)* of collagen type 1 alpha 1 gene and either stress urinary incontinence

(SUI) or pelvic organ prolapse (POP). *RefSNP alleles G/T. Plot presented as risk associated

with minor allele T.

rs1800012 polymorphism

of the COL1A1 gene

was associated with

Prolapse OR 1.3 [1.0, 1.7 n = 838]

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Postpartum UI FI risk calculator

http://www.r-calc.com/ExistingFormulas.aspx?filter=CCQHS

Predispose: Sex, Race

Incite: Childbirth

Promote: BMI

Preamble

Pathophysiology & Etiology of SUI

Epidemiology

Assessment of UI

Management of SUI

Enhorning’s pressure equalisation Theory & Hammock Theory

(urethral backstop)

Conservative & Surgery

Management of intra & post operative complications

Case discussions

Questions